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CONSENSUS DIAGNOSIS: CIMDL
CONSENSUS CIMDL PROBABILITY (0–1, two decimals): 0.81
MERGED ITEMS (Q1–Q10):
Q1: Positive
Q2: Negative
Q3: Positive
Q4: Positive
Q5: Positive
Q6: Positive
Q7: Positive
Q8: Positive
Q9: Negative
Q10: Positive
ADJUDICATOR NOTE (≤5 lines):
– Both summaries agree on CIMDL; probability averaged. Decisive positives in stimulant use (Q1/Q10), whistling/septal damage (Q3), crusting (Q4), nosebleeds (Q5), smell change (Q6), and palatal lesion (Q8).
– Urgent next steps: strict abstinence, sinonasal endoscopy, CT mapping, and biopsy of any indurated viable edge to exclude malignancy/infection.
A past period of snorting stimulants can absolutely explain nosebleeds, crusting, and even a hole in the palate (a drug‑related midline destructive process), and this pattern is more typical of CIMDL than cancer—yet we must rule out cancer and deep infection. Please stop all intranasal drugs now and arrange prompt in‑person care: sinonasal endoscopy and full oral exam; CT of the maxillofacial/paranasal sinuses to map any bony loss (MRI only if a soft‑tissue mass is suspected); and, if any suspicious indurated edge or mass is seen, a small biopsy from the viable margin with cultures. With complete abstinence, inflammation often settles over weeks; existing perforations seldom close on their own, so a temporary obturator can help, and any reconstructive surgery is best delayed until months of proven abstinence and disease quiescence. Seek urgent care sooner for heavy bleeding, rapidly worsening pain/swelling, fever, a new mass or neck lump, vision changes, or weight loss.
DIAGNOSIS: CIMDL
CIMDL PROBABILITY (0–1, two decimals): 0.84
ITEMS (Q1–Q10):
Q1: Negative — “Liquids don’t come out of my nose.”
Q2: Negative — “My voice doesn’t sound especially nasal.”
Q3: Positive — “One side whistles… the middle wall might be damaged.”
Q4: Negative — “I don’t notice heavy crusting.”
Q5: Positive — “I get frequent nosebleeds…”
Q6: Positive — “Smells are dull or missing.”
Q7: Positive — “Pain… behind the nose and at the roof of my mouth.”
Q8: Positive — “There’s a raw, non-healing spot at the roof of my mouth…”
Q9: Negative — “I haven’t had strong treatments before, just rinses and occasional antibiotics.”
Q10: Positive — “I did use nasal stimulants… There’s a slight dip at my nasal bridge.”
SUMMARY (patient-facing, ≤5 lines):
– What we heard: “blocked/whistling nose,” “frequent nosebleeds,” “raw non‑healing spot on the palate,” reduced smell, past intranasal stimulant use, and a dip at the nasal bridge.
– What this might mean: The pattern fits a drug‑related midline destructive process more than typical oral cancer, but we must confirm and rule out cancer/infection.
– Next steps: Stop all intranasal drugs now; arrange ENT/maxillofacial visit for nasal endoscopy and full oral exam; get a CT of sinuses/maxilla/palate; have a small edge biopsy of the palatal/nasal lesion (with cultures) to confirm; use saline rinses and gentle ointment; reconstruction is considered only after abstinence and inflammation settle.
DIAGNOSIS: CIMDL
CIMDL PROBABILITY (0–1, two decimals): 0.78
ITEMS (Q1–Q10):
Q1: Positive — “past period of snorting stimulants”
Q2: Negative — “(no current use stated)”
Q3: Positive — “nosebleeds”
Q4: Positive — “crusting”
Q5: Positive — “possible hole in my palate”
Q6: Negative — “(no septal/saddle‑nose change mentioned)”
Q7: Negative — “(no heavy alcohol/tobacco risk disclosed)”
Q8: Negative — “(no oral mass or nonhealing ulcer reported)”
Q9: Negative — “asking if ‘complete abstinence allow healing’ (no improvement yet)”
Q10: Negative — “(no neck lump, weight loss, severe pain, or trismus reported)”
CLINICAL RATIONALE (≤6 lines):
– Strong CIMDL features: “snorting stimulants,” “nosebleeds,” “crusting,” and a “possible hole in my palate.”
– No OSCC-defining symptoms provided (no mass/ulcer, neck node, weight loss, or persistent focal pain).
– Hence CIMDL-leaning, but malignancy must be excluded with exam ± biopsy if anything looks suspicious.
TRIAGE (≤3 lines):
– CIMDL-leaning → prompt sinonasal endoscopy, strict cessation counseling, and targeted imaging.
– Escalate to urgent biopsy/imaging if any visible mass, indurated ulcer, rapidly enlarging lesion, or neck lump is found.
AIDOC STEPS (brief, one line each):
1. Immediate, complete cessation of all intranasal stimulants; avoid nasal trauma/picking; humidification and saline irrigations for crust control.
2. Arrange in-person sinonasal endoscopy and oral exam (document septum, turbinates, palate; confirm presence/size of perforation).
3. Imaging: CT maxillofacial/paranasal sinuses to map bony/destructive changes; add MRI only if a soft‑tissue mass is suspected.
4. If endoscopy/oral exam shows any suspicious indurated edge or mass, perform a small incisional biopsy at the viable margin; avoid necrotic center.
5. Baseline photos/measurements of any perforation; assess for regurgitation, speech changes, and aspiration risk.
6. Symptom care: saline rinses, gentle emollient to vestibule, pressure control for epistaxis; avoid vasoconstrictor overuse.
7. If palatal perforation is confirmed and symptomatic, fit a temporary obturator; defer definitive surgery until abstinent and disease is quiescent/stable.
8. Reassess at 4–6 weeks of abstinence with repeat exam; if stable/shrinking inflammation, continue conservative care; if progressing, re-image/biopsy.
9. Discuss long-term options: continued obturation vs delayed reconstructive surgery once inflammation has fully settled and no malignancy is present.
Termin vereinbaren
Ordination Dr. Michael Truppe
Albertgasse 3/6 1080 Wien
Telefon 01 408 95 00 66
Email ordination@smile.wien
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